Transcript Slide 1

Partnership in Performance:
Leadership and Mental
Health Care on Deployment
Presentation to:
CIOR Symposium,
Summer Congress
Copenhagen, 2012
Captain Stan French, CD BSc RN
Mental Health Nurse
Your health - Our mission
Votre santé - Notre mission
Disclosure
• I am a member of the
Canadian Forces
Primary Reserve
• I have not received any
third-party funding
• I am not endorsing a
product or service
Your health - Our mission
Votre santé - Notre mission
Outline
• Review treatment models that help prevent PTSD
• Look at the ‘Road to Mental Readiness’ training program
• See how leadership plays an important mental health role
during pre-deployment and while deployed
• Provide case studies as examples with a focus on the role
of leadership as part of a successful outcome
• The extra importance of this to Reservists
Your health - Our mission
Votre santé - Notre mission
Cognitive Behavioural Therapy
Your health - Our mission
Votre santé - Notre mission
CBT for ASD to prevent PTSD
• 2008 Meta-Analysis by Kornor et al: Early (within 3 months)
Trauma-Focused CBT for patients with ASD is effective in
preventing chronic PTSD
• Bryant et al in 2003 found the benefit of CBT in first month
after trauma for ASD patients remains present at four-year
follow-up
• Bryant et al in 2008 RCT showed that when treating ASD with
CBT (5 weekly 90 minute sessions), exposure based therapy
was more effective than cognitive restructuring in reducing
PTSD symptoms measured at 6 month follow-up
• Roberts et al 2009, trauma-focused CBT within 3 months of the
event had the greatest effect for those patients who met the
ASD diagnostic criteria
Your health - Our mission
Votre santé - Notre mission
Guidelines for the Treatment of ASD
• Key recommendations from Australia in 2007 include
the use of trauma-focused CBT for effective treatment
of ASD and PTSD
• From 2010 U.S. VA, DoD PTSD Guidelines: Consider
early brief intervention (4 to 5 sessions) of CBT that
includes exposure-based therapy, alone or combined
with a component of cognitive re-structuring therapy
for patients with significant early symptom levels,
especially those meeting diagnostic criteria for ASD.
Your health - Our mission
Votre santé - Notre mission
Your health - Our mission
Votre santé - Notre mission
What do we know so far?
• Best practice for preventing chronic PTSD is not to
treat everyone the same that experiences a trauma, it is
to treat with CBT only those who develop symptoms
of ASD
• That’s great, but how do we get the soldiers that need
MH Care to the therapists that can help them at the
right time?
• Many challenges: operational needs, stigma, education
of the individual soldier and the chain of command
and medical system of referral.
Your health - Our mission
Votre santé - Notre mission
Your health - Our mission
Votre santé - Notre mission
Mental Health Continuum Model
HEALTHY
REACTING
Normal functioning
Common and
reversible distress
Your health - Our mission
Votre santé - Notre mission
INJURED
Severe and persistent
functional impairment
ILL
Clinical disorder
Severe functional impairment
Mental Health Continuum Model
HEALTHY
REACTING
INJURED
ILL
Chain of Command
Chain of Command
Chain of Command
Chain of Command
Health Services
Health Services
Health Services
Health Services
Your health - Our mission
Votre santé - Notre mission
Individual Coping
HEALTHY
REACTING
Maintain healthy lifestyle
Focus on task at hand
SMART goal setting
Controlled breathing
Challenge negative self talk
Visualization/Mental rehearsal
Nurture a support system
Recognize limits take breaks
Rest, relaxation, recreation
Your health - Our mission
Votre santé - Notre mission
INJURED
ILL
Talk to someone; ask for help
Tune into own signs of distress
Make self care a priority
Get help sooner, not later
Maintain social contact, don’t withdraw
Follow care recommendations
Key Role of Leaders
HEALTHY
Lead by example
Get to know your personnel
Foster healthy climate
Identify and resolve
problems early
Deal with performance
issues promptly
Demonstrate genuine
concern
Provide opportunities for
rest
Provide mental health first
aid after adverse situations
Provide realistic training
opportunities
REACTING
INJURED
Lead to BE the
Resilience Reservoir
Watch for behaviour
changes
Adjust workload as
required
Know the resources &
how to access them
Reduce barriers to helpseeking
Encourage early access to
care
Consult with CoC/HS as
required
Your health - Our mission
Votre santé - Notre mission
ILL
Involve MH resources
Demonstrate genuine
concern
Respect confidentiality
Minimize rumours
Respect medical
employment limitations
Appropriately employ
personnel
Maintain respectful contact
Involve members in social
support
Seek consultation as
needed
Manage unacceptable
behaviours
The PIES Model for treating CSR
•
•
•
•
Proximity: to the soldier’s deployed unit
Immediacy: treatment as soon as required
Expectancy: of recovery and return to duty
Simplicity: with focus on rest, nutrition, exercise,
and normalization
• Current (draft) NATO STANAG
Your health - Our mission
Votre santé - Notre mission
PIE Model History
•
•
•
•
First introduced by the French in 1915
Adopted by the British in 1916
US adopted forward psychiatry upon entry in WW1
Return to duty rates for stress casualties “were as high as 80% for
those treated at advanced field hospitals” as reported by Babington
• Solomon et al 20 year longitudinal study of IDF CSR casualties of the
1982 Lebanon War found those who received frontline treatment had
lower rates of PTSD and when immediacy and expectancy were part
of the treatment there was a cumulative effect
• Jones et al, 2010, confirmed the benefit of Forward Psychiatry
looking at soldiers referred to Field MH Teams in Iraq between 2003
and 2007. With over 70% of those treated by the FMHT returning to
their unit and continuing to serve for more than 2 years, the
conclusion was that forward psychiatry was effective as measured by
work outcome
Your health - Our mission
Votre santé - Notre mission
The problem with PIES
• Which is true: does a RTD cause a better prognosis or does
a better prognosis make it more likely a soldier will RTD?
• Programs that treat CSR in a time-limited fashion with an
expectation that treatment duration will be sufficient for
RTD are not patient focussed care and may precipitate
relapse, need for further care and reduce unit strength.
• Much of the data supporting PIES is based on RTD (or
functional outcome) rather than on clinical efficacy.
Your health - Our mission
Votre santé - Notre mission
PIES and the Sick Role
• Short term sick role necessary to accept help: “I’m injured
and I won’t get better unless I get medical attention.”
• Expectancy: “I will get better and RTD with my unit.”
• Long term or chronic sick role (adopted most often when
evacuated out of theatre): “I’m injured and I’ll never be
well enough to rejoin my unit.”
• Without proximity, expectancy of recovery is difficult.
Your health - Our mission
Votre santé - Notre mission
Patient-focussed Care, CBT, and PIES
• Soldier assessed by MH: can be self referred, encouraged by
leadership to talk with MH, or be a medical referral
• If CSR does not meet ASD: Treat as per PIES with
psychological first aid, RTD when appropriate.
• If CSR meets ASD Dx: Treat with CBT within theatre, with the
expectancy of recovery and RTD upon successful completion of
treatment, and the immediacy of treatment is based on the
patient’s needs. The course of treatment will be as compressed
and brief as possible to prevent loss of warrior ethos, to
reconnect with the support of his unit, and to reinforce his sense
of value to the mission.
• Exposure therapy (as part of TF-CBT) is both imaginal (with
the therapist in session), and in vivo (as the soldier works
toward full RTD)
Your health - Our mission
Votre santé - Notre mission
Implication for Reservists
• If pre-deployment training is not as thorough as it is for their
Regular Force counterparts, the Reservists will be more
vulnerable to Operational Stress Injuries (OSI)
• If a Reservist is an augmentee in a unit he may feel more
isolated, which also increases OSI vulnerability
• Once home and back in civilian life, a Reservist who develops
an OSI has less chance of maintaining the support of his
buddies from deployment
• Post-deployment health screenings are more difficult to enforce
for Reservists which can lead to undiagnosed and untreated OSI
Your health - Our mission
Votre santé - Notre mission
Case Study One
• Soldier involved in fire fight during night insertion
• Unable to board a/c for next mission
• c/o severe sleep disturbance, nightmares, exaggerated
startle response, irritable, and very poor concentration
• Assessment included the start of exposure therapy with
description of the last mission
• Cognitive restructuring used for guilt: he missed mission
• Psychiatrist Rx Prazosin to reduce nightmares
• Education with expectancy, and aerobic exercise
Your health - Our mission
Votre santé - Notre mission
Case Study One
• Intense therapy schedule of daily sessions for three
days then every other day for a week
• Gradual return to work with desensitization of triggers
• Expectancy reinforced as symptoms decreased and
confidence increased
• D/C from care based on condition, prognosis, and
agreement of patient. RTD in less than two weeks.
Your health - Our mission
Votre santé - Notre mission
Case Study Two
•
•
•
•
Clerk based at KAF exposed to rocket attacks at a FOB
Had a panic attack when ordered to a FOB again
Treatment: expectancy (going to the FOB is the best thing)
MWO provided the same message but also acknowledged that
the clerk’s pre-deployment training did not include the FOB
environment (empathy)
• MWO also assured the clerk that he would be there as a leader
• The mission was completed and the clerk returned to KAF in
better mental health than prior to the second FOB tasking
Your health - Our mission
Votre santé - Notre mission
Case Study Three
• Soldier sent to MH by CoC after minor conduct infraction
• CSR treated with the PIES model, RTD
• Four of his buddies were waiting to make an appointment to see
me the next morning
• Leadership did the right thing by recognizing that an unusual
behaviour was linked to a CSR
• Access to MH care would have been improved if predeployment training had included the ‘Road to Mental
Readiness’ because of reduced stigma and improved self
assessment
Your health - Our mission
Votre santé - Notre mission
Summary for Health Services
• CBT is effective in treating CSR when the criteria for ASD
is met. Those treated are less likely to develop PTSD.
• The principles of the PIES model are sound but the
therapeutic benefit for each pt. is not clearly established.
The best outcome for an individual patient does not
necessarily come from a ‘one size fits all’ approach.
• The best possible outcome (for the patient and the mission)
requires a combination of patient focussed CBT when used
within the framework of the PIES Model.
• Implication for resource allocation: treat early, save a lot!
Your health - Our mission
Votre santé - Notre mission
Summary for Leadership
• Realistic pre-deployment training builds resiliency through
desensitization. Train for the worst case scenario.
• Pre-deployment training should include a mental health
readiness component to reduce barriers to care, increase
individual awareness for self assessment, improve coping
skills that increase resiliency and performance under
extreme stress, and defines everyone’s MH responsibility.
• The better the leadership skills on deployment, the more
mentally fit the subordinates.
• An effective partnership between leaders and MH will
enhance individual and unit performance while deployed.
Your health - Our mission
Votre santé - Notre mission
QUESTIONS
Your health - Our mission
Votre santé - Notre mission